Use of health services one year before primary colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) patient pathways focus typically on periods after confirmed diagnosis and only limited data are available on pathways prior to cancer diagnosis. The aim of the study was to describe the use of health services (HS) one year before diagnosis among CRC patients in Finland. We also studied the role of sex, age, stage, and university hospital district in relation to the use of HS during the pre-diagnostic phase. This information is expected to bring light on the question why CRC is often not found in its early stages. METHODS: Incident CRC cases (N = 3115) concerning year 2015 were retrieved from the Finnish Cancer Registry and linked with data from the Finnish Institute for Health and Welfare on primary or specialised care outpatient visits or inpatient episodes over one year prior to CRC diagnosis. We modelled the average number of HS events per patient using Poisson regression model with log-link. Change points for monthly HS event rates and 95% CIs one year before diagnosis were evaluated using Poisson broken line regression models. RESULTS: Around 10% of patients diagnosed in 2015 had no events prior to cancer leaving 2816 CRCs in the study. Of all pre-diagnostic events (N = 23268), 86% were outpatient events and 14% inpatient episodes. More than half of the inpatient episodes (65%) started as urgent admissions. The use of HS started to increase 3-4 months before diagnosis. The average number of pre-diagnostic HS events per patient varied by sex, age, stage and university hospital district. Overall, men had more events per patient than women and older patients had more events than younger patients. CONCLUSIONS: The amount of inpatient episodes starting as urgent admissions indicate potential bottlenecks in the access to health services. An increase in service use only 3-4 months prior to diagnosis reflects a need for advice both for health care professionals and the general population in recognising symptoms of CRC.

Study protocol for an epidemiological study 'Multimorbidity - identifying the most burdensome patterns, risk factors and potentials to reduce future burden (MOLTO)' based on the Finnish health examination surveys and the ongoing register-based follow-up.

INTRODUCTION: Multimorbidity, defined as the co-occurrence of two or more long-term medical conditions, is an increasing public health concern worldwide causing enormous burden to individuals, healthcare systems and societies. The most effective way of decreasing the burden caused by multimorbidity is to find tools for its successful prevention but gaps in research evidence limit capacities to develop prevention strategies. The aim of the MOLTO study (Multimorbidity - identifying the most burdensome patterns, risk factors and potentials to reduce future burden) is to provide novel evidence required for cost-effective prevention of multimorbidity by defining the multimorbidity patterns causing the greatest burden at the population level, by examining their risk and protective factors and by estimating the potentials to reduce the future burden. METHODS AND ANALYSIS: The MOLTO study is based on the data from the Finnish population-based cross-sectional (FINRISK 2002-2012, FinHealth 2017 the Migrant Health and Well-being Study 2010-2012) and longitudinal (Health 2000/2011) health examination surveys with individual-level link to administrative health registers, allowing register-based follow-up for the study participants. Both cross-sectional and longitudinal study designs will be used. Multimorbidity patterns will be defined using latent class analysis. The burden caused by multimorbidity as well as risk and protective factors for multimorbidity will be analysed by survival analysis methods such as Cox proportional hazards and Poisson regression models. ETHICS AND DISSEMINATION: The survey data have been collected following the legislation at the time of the survey. The ethics committee of the Hospital District of Helsinki and Uusimaa has approved the data collection and register linkages for each survey. The results will be published as peer-reviewed scientific publications.

The risk of renal comorbidities in celiac disease patients depends on the phenotype of celiac disease.

BACKGROUND: An increased risk of kidney disease in patients with celiac disease has been reported, but the association has remained obscure. Only few studies have investigated the association between renal comorbidities and dermatitis herpetiformis, a cutaneous manifestation of celiac disease. OBJECTIVES: We investigated whether patients with different phenotypes of celiac disease are at higher risk of kidney diseases than age- and sex-matched references. METHODS: The diagnoses of glomerulonephritis, diabetic nephropathy, interstitial nephritis, and end-stage renal disease obtained from the National Hospital Discharge Register between 1970 and 2015 were identified in celiac disease (Marsh III, n = 1072) and dermatitis herpetiformis (n = 368) patients diagnosed at Tampere University Hospital catchment region and in 4296 reference subjects. Using the Cox proportional hazards model, we compared the risk of kidney diseases between patients and references. The study protocol was approved by the Regional Ethics Committee of Tampere University Hospital (R16090). As the study was register based, no consent from patients was required. RESULTS: Even after adjusting for type 1 diabetes, celiac disease was associated with an elevated risk of kidney disease (hazard ratio [HR] 1.85, 95% confidence interval [CI] 1.12-3.03), glomerulonephritis (HR 3.37, 95% CI 1.64-6.95), and IgA nephropathy (IgAN) (HR 18.98, 95% CI 2.29-157.63). No similarly elevated risk was found among dermatitis herpetiformis patients (HR 1.50, 95% CI 0.63-3.55; HR 2.21, 95% CI 0.77-6.38; and HR 5.87, 95% CI 0.53-64.79, respectively). CONCLUSION: Celiac disease patients were at increased risk of kidney diseases, notably IgAN. The risk was dependent on the celiac disease phenotype and was not seen in patients with dermatitis herpetiformis. Awareness of possible renal manifestations is recommended when treating celiac disease patients.

Risk of fractures in dermatitis herpetiformis and coeliac disease: a register-based study.

Objectives: Dermatitis herpetiformis (DH) is a cutaneous manifestation of coeliac disease. Bone fracture risk is increased in coeliac disease, but little knowledge exists about bone complications in DH. This study aimed to evaluate the risk of hip and other hospital-treated fractures in DH and coeliac disease in a high prevalence area with good adherence to a gluten-free diet. Materials and methods: Hip, proximal humerus, wrist and ankle fractures in 368 treated DH and 1076 coeliac disease patients between 1970 and 2015 were reviewed from the National Hospital Discharge Register. Hip fracture incidence rates for DH and coeliac disease patients were compared to those for the general population. The overall fracture risk for DH was compared to coeliac disease. Results: The hip fracture incidence rates for DH and coeliac disease patients did not differ from the general population. In females aged 80-89, the hip fracture incidence was higher in DH than in coeliac disease, but the risk for any hospital-treated fracture was lower in DH compared to coeliac disease (adjusted HR 0.620, 95% CI 0.429-0.949). The DH and coeliac disease patients with hospital-treated fractures were diagnosed at an older age, but the degree of small bowel mucosal damage did not significantly differ between patients with and without fractures. Conclusion: The incidence of hip fracture is not increased in treated DH or coeliac disease in an area with high awareness and dietary compliance rates. However, patients with DH seem to have a lower risk for fractures overall compared to coeliac disease.

Comparison of Health Care Costs Between Claimants and Nonclaimants in the No-Fault Compensation System of Finland.

OBJECTIVES: If patients experience health care-related adverse events, they may claim for compensation. Adverse events of claimants are generally more severe and presumably involve higher health care costs than those of nonclaimants. The aim of this study was to estimate the cost differential between claimants and nonclaimants in the no-fault system in Finland. METHODS: We compiled register data on patients having had coronary artery bypass grafting (CABG, n = 20,500), total hip arthroplasty (n = 17,506), or knee arthroplasty (TKA, n = 18,512) and calculated risk-adjusted cost differentials by using a gamma distributed, log-linked generalized linear model. The explained variable comprised costs, whereas the main explanatory variables were whether the patient filed a claim and whether he or she received compensation. RESULTS: Uncompensated claimants had higher admission costs (CABG, &OV0556;3660, 29%; total hip arthroplasty, &OV0556;418, 5%; TKA, &OV0556;359, 4%) compared with nonclaimants, whereas the differential between compensated claimants and uncompensated claimants was statistically insignificant. Significant associations emerged concerning CABG 1-year costs: uncompensated claimants had &OV0556;12,990 (71%) higher costs than nonclaimants, whereas compensated claimants had &OV0556;6388 (20%) higher costs than uncompensated claimants. CONCLUSIONS: Although the precise cost differentials may be specific to Finland, the implications may apply also to other countries. (1) Excess costs of claimants should motivate efforts to reduce adverse events. (2) Analyses of claims to improve patient safety should not be restricted to compensated claims only but should equally concern uncompensated claims. A further implication regarding Finland is that additional approaches to identify and report adverse events are necessary.

Morbidity and Health Care Costs After Early Term Birth.

BACKGROUND: Early term birth is associated with increased need for hospital care during the early postnatal period. The objective of this study was to assess the morbidity and health care-related costs during the first 3 years of life in children born early term. METHODS: Data come from a population-based birth cohort study in the municipalities of Helsinki, Espoo, and Vantaa, Finland using data from the national medical birth register and outpatient, inpatient, and primary care registers. All surviving infants born in 2006-08 (n = 29 970) were included. The main outcome measures were morbidities, based on ICD-10 codes recorded during inpatient and outpatient hospital visits, and health care costs, based on all care received, including well child visits (specialised care, primary care, private care, and medications). RESULTS: 7.0% of children born full term had at least one of the studied morbidities by 3 years of age. This percentage was significantly higher in children born early term: 8.6% (adjusted odds ratio 1.2, 95% confidence interval (CI) 1.1, 1.4). The increased morbidity of children born early term was attributed to obstructive airway diseases and ophthalmological and motor problems. Health care-related costs during the first 3 years of life were 4813€ (95% CI 4385, 5241) per child in the early term group, higher than for full term children 4047€ (95% CI 3884, 4210). CONCLUSIONS: Infants born early term have increased morbidity and higher health care-related costs during early childhood than full term infants. Early term birth seems to be associated with a health disadvantage.

Association between household income and the outcome of arthroplasty: a register-based study of total hip and knee replacements.

INTRODUCTION: Previous research findings regarding the association between the outcomes of total hip and knee arthroplasty and patients' socioeconomic status have been contradictory. Consequently, we wanted to analyse whether individual-level household income was associated with the risk of revision arthroplasty and whether the time span in days from the primary arthroplasty to the revision operation varied according to income quintile. MATERIALS AND METHODS: All first total hip and knee arthroplasties performed due to primary osteoarthritis in Finland from 1998 to 2007 were included in the study. Cox proportional hazard regression modelling was applied in the analysis regarding the risk of revision after the primary operation, while Poisson regression modelling was applied in the analysis regarding differences in the time from the primary to the revision operation between income quintiles. RESULTS: The relationship between household income and the risk of revision arthroplasty was not statistically significant. The relationship remained insignificant, even when age, sex, and other confounding factors were adjusted for or analyses concerned revision in short or long term. In both the total hip arthroplasty and knee arthroplasty populations, patients in the lowest income quintiles underwent revision surgery earlier than patients in the highest income groups, but this difference was not statistically significant. CONCLUSION: The quality of arthroplasty as measured by the risk of revision does not seem to depend on patients' income quintile.

The development of differences in hospital costs accross income groups in Finland from 1998 to 2010.

OBJECTIVE: To quantify differences in hospital costs between socioeconomic groups and the development over time. METHODS: Register data on somatic specialised hospital admissions for patients aged between 25 and 84 in Finland in 1998-2010 were used with income data individually linked to them. The cost of an admission was calculated by multiplying the number of a patient's inpatient days by the inpatient day cost of the patient's DRG. We calculated age-standardised admission costs per resident and per user as well as costs per inpatient day and concentration indices separately for men and women. RESULTS: Hospital admission costs reduced with increasing income. The difference between the extreme income quintiles was more than 50% throughout the study period, and this difference widened. However, the cost per inpatient day was more than 20% higher in the highest income group. The differences between income groups were the most prominent in disease categories involving surgery. CONCLUSIONS: The growth between socioeconomic groups in hospital costs is presumably mainly due to increasing differences in morbidity. More attention needs to be paid to prevention of health inequalities and access to and content of primary care among low-income groups in order to decrease the need for hospitalisations.

Factors predisposing to claims and compensations for patient injuries following total hip and knee arthroplasty.

BACKGROUND AND PURPOSE: Factors associated with malpractice claims are poorly understood. Knowledge of these factors could help to improve patient safety. We investigated whether patient characteristics and hospital volume affect claims and compensations following total hip arthroplasty (THA) and knee arthroplasty (TKA) in a no-fault scheme. METHODS: A retrospective registry-based study was done on 16,646 THAs and 17,535 TKAs performed in Finland from 1998 through 2003. First, the association between patient characteristics-e.g., age, sex, comorbidity, prosthesis type-and annual hospital volume with filing of a claim was analyzed by logistic regression. Then, multinomial logistic regression was applied to analyze the association between these same factors and receipt of compensation. RESULTS: For THA and TKA, patients over 65 years of age were less likely to file a claim than patients under 65 (OR = 0.57, 95% CI: 0.46-0.72 and OR = 0.65, CI: 0.53-0.80, respectively), while patients with increased comorbidity were more likely to file a claim (OR = 1.17, CI: 1.04-1.31 and OR = 1.14, CI: 1.03-1.26, respectively). Following THA, male sex and cemented prosthesis reduced the odds of a claim (OR = 0.74, CI: 0.60-0.91 and OR = 0.77, CI: 0.60-0.99, respectively) and volume of between 200 and 300 operations increased the odds of a claim (OR = 1.29, CI: 1.01-1.64). Following TKA, a volume of over 300 operations reduced the probability of compensation for certain injury types (RRR = 0.24, CI: 0.08-0.72). INTERPRETATION: Centralization of TKA to hospitals with higher volume may reduce the rate of compensable patient injuries. Furthermore, more attention should be paid to equal opportunities for patients to file a claim and obtain compensation.

Can patient injury claims be utilised as a quality indicator?

OBJECTIVES: To examine the association between patient injury claims and well-known quality indicators and to assess whether claims can be utilised in performance measurement. METHODS: Data were derived from administrative registers and comprised hip and knee replacement patients (n=34181) in Finland from 1998 to 2003. Hospital-level correlations were calculated between claims and quality indicators (5-year revision rate, 1-year deep infection rate, and 14-day readmission rate), while logistic regression analysis was used to analyze patient-level data for an association between claims and quality indicators. RESULTS: Correlations between claims and revisions as well as claims and infections were statistically significant, with correlation coefficients ranging from 0.21 to 0.62. In the regression analysis, both the revision and the infection indicator had a positive and statistically significant association with filing a claim (OR 1.002; 95% CI 1.001-1.003 and 1.001; 1.00005-1.001, respectively) and obtaining compensation (1.003; 1.001-1.005 and 1.001; 1.0003-1.002, respectively). CONCLUSIONS: A claims indicator has the potential to be applied as a quality indicator. It should be complemented, however, with other indicators or actions to improve its acceptability by health professionals and to mitigate its possible undesirable effects.

Patient and hospital characteristics associated with claims and compensations for patient injuries in coronary artery bypass grafting in Finland.

OBJECTIVES: To analyse the association between individual patients' risk factors and rates of claims and compensations for patient injuries in an insurance scheme in which proof of negligence is not required. And to explore whether either hospital productivity or volume of procedures is related to claims and compensation rates. METHODS: A two-step sequential logistic regression was applied on data collected from administrative registers. It included 17,834 patients who had undergone coronary artery bypass grafting at public hospitals in Finland between 1998 and 2002. The main outcome measure was the odds of claiming and receiving compensation. RESULTS: Men were less likely to claim compensation (odds ratio [OR] 0.66; 95% confidence interval 0.54-0.81), but among those having claimed were more likely to receive compensation (OR 2.08; 1.15-3.75) than women. Patients with a co-morbidity were more likely to claim (OR 1.29; 1.06-1.57), but among those having claimed were less likely to receive compensation (OR 0.52; 0.31-0.86) than those without a co-morbidity. Advanced age reduced the probability of claiming (OR 0.71; 0.52-0.96). CONCLUSIONS: Although high-risk patients file a claim more frequently than low-risk patients, the latter have a higher probability of getting their claims accepted and receiving compensation. This risk pattern is probably a reflection of compensation practices related to patient injuries involving an infection.

Developing the formula for state subsidies for health care in Finland.

AIM: The aim was to generate a research-based proposal for a new subsidy formula for municipal healthcare services in Finland. METHODS: Small-area data on potential need variables, supply of and access to services, and age-, sex- and case-mix-standardised service utilisation per capita were used. Utilisation was regressed in order to identify need variables and the cost weights for the selected need variables were subsequently derived using various multilevel models and structural equation methods. RESULTS: The variables selected for the subsidy formula were as follows: age- and sex-standardised mortality (age under 65 years) and income for outpatient primary health services; age- and sex-standardised mortality (all ages) and index of overcrowded housing for elderly care and long-term inpatient care; index of disability pensions for those aged 15-55 years and migration for specialised non-psychiatric care; and index of living alone and income for psychiatric care. CONCLUSION: Decisions on the amount of state subsidies can be divided into three stages, of which the first two are mainly political and the third is based on the results of this study.

Health care systems in transition: Finland

The Health Systems in Transition (HiT) series provide detailed descriptions of health systems in the countries of the WHO European Region as well as some additional OECD countries. An individual health system review (HiT) examines the specific approach to the organization, financing and delivery of health services in a particular country and the role of the main actors in the health system. It describes the institutional framework, process, content, and implementation of health and health care policies. HiTs also look at reforms in progress or under development and make an assessment of the health system based on stated objectives and outcomes with respect to various dimensions (health status, equity, quality, efficiency, accountability).